# Composition: HDR (1) - HL7 Europe Hospital Discharge Report v1.0.0-alpha

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **Composition: HDR (1)**

## Example Composition: Composition: HDR (1)

Profile: [Composition (HDR)](StructureDefinition-composition-eu-hdr.md)

**status**: Final

**type**: Hospital Discharge summary

**encounter**: [Encounter: status = finished; class = inpatient encounter (ActCode#IMP); serviceType = Diabetes mellitus screening (procedure); period = 2025-04-01 08:45:00+0000 --> 2025-04-10 11:00:00+0000; reasonCode = Prediabetes (finding)](Bundle-HDR-Luigi-De-Luca-Example.md#urn-uuid-7c9a2bf1-507f-4d43-b06e-d78e9670379d)

**date**: 2025-04-29 13:30:00+0100

**author**: [PractitionerRole](Bundle-HDR-Luigi-De-Luca-Example.md#urn-uuid-74403dd8-bb1b-45f9-bb69-e843dfaf45e9)

**title**: Hospital Discharge Report

**custodian**: [Organization Casa di cura Villa S. Giuliana](Bundle-HDR-Luigi-De-Luca-Example.md#urn-uuid-a61a91f8-b8f2-4947-9a64-5165ea380a38)



## Resource Content

```json
{
  "resourceType" : "Composition",
  "id" : "b9dc409d-ec81-4556-9fac-4dc3f731c199",
  "meta" : {
    "profile" : ["http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr"]
  },
  "status" : "final",
  "type" : {
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "34105-7",
      "display" : "Hospital Discharge summary"
    }]
  },
  "subject" : {
    "reference" : "urn:uuid:b01a2623-e219-41d2-8e78-1fa1439751d0"
  },
  "encounter" : {
    "reference" : "urn:uuid:7c9a2bf1-507f-4d43-b06e-d78e9670379d"
  },
  "date" : "2025-04-29T13:30:00+01:00",
  "author" : [{
    "reference" : "urn:uuid:74403dd8-bb1b-45f9-bb69-e843dfaf45e9"
  }],
  "title" : "Hospital Discharge Report",
  "custodian" : {
    "reference" : "urn:uuid:a61a91f8-b8f2-4947-9a64-5165ea380a38"
  },
  "section" : [{
    "title" : "Admission evaluation",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "67851-6"
      },
      {
        "system" : "http://loinc.org",
        "code" : "67852-4",
        "display" : "Hospital Admission evaluation note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi De Luca, a 57-year-old male, was admitted on 1st April following a pre-diabetic episode characterized by episodes of fatigue, polyuria, and increased thirst. Recent routine blood tests showed elevated fasting blood glucose and HbA1c levels that required further investigation.<p/>When Mr De Luca arrived in the morning we recorded a fasting blood glucose level at 180 mg/dL. His HbA1c level was 7.8%. He seemed to be dehydrated, so that he immediately was sent to the ward for a full breakfast and fluid substitution.</div>"
    }
  },
  {
    "title" : "Family History",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "10157-6",
        "display" : "History of family member diseases note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).</div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:635c22e7-d7f1-45ad-9b4d-d4fe35239085"
    },
    {
      "reference" : "urn:uuid:3fbdfbe1-9d70-47ec-ac05-3e30b063365a"
    }]
  },
  {
    "title" : "Vital signs note",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "8716-3",
        "display" : "Vital signs note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Vital signs</th><th>1st April</th><th>10th April</th></tr></thead><tbody><tr><td>Body weight</td><td>109 kg</td><td>108 kg</td></tr><tr><td>Body height</td><td>177 cm</td><td/></tr><tr><td>Blood Pressure</td><td>155 / 95 mmHg</td><td>150 / 90 mmHg</td></tr></tbody></table></div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:f0113857-b9b7-429b-8893-b645a38ae20a"
    },
    {
      "reference" : "urn:uuid:065c918f-730a-47f8-938a-7ad54618037b"
    },
    {
      "reference" : "urn:uuid:81783ae4-c36d-424f-8cea-fe7d3407a36b"
    },
    {
      "reference" : "urn:uuid:a19e48e1-2271-4cdb-9c76-b0626c7a5363"
    },
    {
      "reference" : "urn:uuid:fd7f7580-5788-45dd-88ec-dca615d69c7d"
    }]
  },
  {
    "title" : "Tobacco use",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "11367-0",
        "display" : "History of Tobacco use"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">The patient smokes &quot;a few&quot; cigarettes per day.</div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:67152b1b-0ffa-4b8f-8b6a-a3d71d4d58b6"
    }]
  },
  {
    "title" : "Hospital course note",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "8648-8",
        "display" : "Hospital course note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">During the hospital stay from 1 to 10 April, Mr. De Luca underwent a series of diagnostic tests, consultations and initial treatment.<p/>Throughout his hospital stay, Mr. De Luca was monitored closely. His blood sugar levels improved modestly with the introduction of Metformin, and no acute complications were observed.</div>"
    }
  },
  {
    "title" : "Significant Observation Results",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "30954-2",
        "display" : "Relevant diagnostic tests/laboratory data note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Blood Glucose Monitoring Regular monitoring of fasting blood glucose levels and random blood glucose levels. Fasting glucose levels consistently ranged between 140-180 mg/dL.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Fasting glucose [Moles/volume] in Blood</th><th>Range</th></tr></thead><tbody><tr><td>1 April 2025</td><td>180 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>2 April 2025</td><td>140 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>3 April 2025</td><td>150 mg/dL</td><td>70 to 99 mg/dL</td></tr><tr><td>5 April 2025</td><td>140 mg/dL</td><td>70 to 99 mg/dL</td></tr></tbody></table>HbA1c Test: An HbA1c level of 7.2%, confirming the diagnosis of Type 2 Diabetes Mellitus.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Hemoglobin A1c [Mass/volume] in Blood</th><th>Range</th></tr></thead><tbody><tr><td>1 April 2025</td><td>7.2%</td><td>&lt; 5.7%</td></tr></tbody></table>Oral Glucose Tolerance Test (OGTT): This test further confirmed impaired glucose tolerance.<table class=\"hl7__hdr\"><thead><tr><th>Date</th><th>Glucose [Mass/volume] in Serum or Plasma --1 hour post dose glucose</th><th>Range</th></tr></thead><tbody><tr><td>2 April 2025</td><td>180 mg/dL</td><td>70 to 99 mg/dL</td></tr></tbody></table></div>"
    }
  },
  {
    "title" : "Significant procedures",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "10185-7",
        "display" : "Hospital discharge procedure note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Lifestyle Consultation: Mr. De Luca met with a dietitian to discuss necessary changes in his diet, focusing on a low glycemic index diet and the need to monitor carbohydrate intake. He was also advised to engage in regular physical activity.<p/>Diabetes Education: Mr. De Luca attended educational sessions on diabetes management, including the importance of regular blood sugar monitoring, recognizing hypoglycemia and hyperglycemia symptoms, and foot care.<p/>Starting Pharmacotherapy with Metformin.</div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:92ffc1fd-71ff-4d54-bc06-25d9e1e1fea0"
    },
    {
      "reference" : "urn:uuid:a74a3dca-92fa-4b71-8e70-89a07ac74bc3"
    },
    {
      "reference" : "urn:uuid:53a8c3c3-5d1b-4950-87bc-fddae2ebc079"
    }]
  },
  {
    "title" : "Medications",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "87232-5",
        "display" : "Medication administration.brief"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Metformin 500 mg twice daily was started as the first-line treatment to help control blood glucose levels.<table class=\"hl7__hdr\"><thead><tr><th>Medication administrations</th><th>Dose/Frequency</th><th>SNOMED</th></tr></thead><tbody><tr><td>Metformin, oral tbl</td><td>500 mg, twice / day</td><td>765507008</td></tr><tr><td>Multivitamines</td><td>daily</td><td/></tr></tbody></table></div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:bda0b497-c9f2-47ca-8339-da1d379cb2f4"
    }]
  },
  {
    "title" : "Follow-up",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "18776-5",
        "display" : "Plan of care note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Follow-up</th><th>Activity</th><th>SNOMED</th></tr></thead><tbody><tr><td>Endocrinology Clinic</td><td>Follow-up appointment in 2 weeks to assess response to treatment</td><td>306118006 Referral to endocrinology service (procedure)</td></tr><tr><td>Dietitian Consultation</td><td>Appointment in 1 month for further dietary planning</td><td>103699006 Referral to dietitian (procedure)</td></tr><tr><td>Routine Blood tests</td><td>Repeat HbA1c in 3 months</td><td>43396009 Hemoglobin A1c measurement (procedure)</td></tr></tbody></table></div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:b84038f8-9541-4c5b-93b0-a7f1b8e55bd3"
    }]
  },
  {
    "title" : "Diagnosis at Discharge",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "11535-2",
        "display" : "Hospital discharge diagnosis note"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table class=\"hl7__hdr\"><thead><tr><th>Discharge Diagnoses</th><th>Codes</th></tr></thead><tbody><tr><td>Type 2 Diabetes Mellitus – Newly diagnosed.</td><td><ul><li>Type 2 diabetes mellitus E11 (ICD-10)</li><li>Diabetes mellitus type 2 (disorder) 44054006 (SNOMED)</li></ul></td></tr></tbody></table></div>"
    },
    "entry" : [{
      "reference" : "urn:uuid:a5bf69e4-24db-48a8-9eda-71516dcaf1d9"
    }]
  },
  {
    "title" : "Hospital Discharge Instructions",
    "code" : {
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "8653-8",
        "display" : "Hospital Discharge Instructions"
      }]
    },
    "text" : {
      "status" : "additional",
      "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Instructions at Discharge to Mr. De Luca<ul><li>Continue home glucose monitoring and to maintain a log for review at follow-up appointments.</li><li>Continue with the prescribed medication and lifestyle changes.</li><li>Monitor blood sugar levels at home regularly.</li><li>Adhere to the diabetic diet plan.</li><li>Stay physically active, with at least 30 minutes of moderate exercise most days of the week.</li><li>Return to the emergency department for any signs of hyperglycemia (e.g., excessive thirst, urination, confusion) or hypoglycemia (e.g., sweating, shakiness, confusion).</li></ul></div>"
    }
  }]
}

```
